Book review – Unequal Health: The scandal of our times

Unequal Health: the scandal of our times by Professor Danny Dorling is a book that aims to explain that ‘health inequalities are the most important inequalities of all’. It is a text that readers of People, Place and Policy will find extremely valuable. The book is a collection of articles, lectures, papers, and reports that explore where inequalities are at their most stark and discriminating. For example, one of the most immediate inequalities is that a child born in 2012 in Glasgow will have a life expectancy of 72.6 years for boys and 78.5 for girls. This is compared to the average life expectancy for the whole United Kingdom of 78.9 for males and 82.7 for females. Along with new and updated chapters Unequal Health adds to previous publications by the same author that have examined inequalities of different types. This body of work has been the cornerstone of Dorling’s recent publications, including The 32 Stops: Lives on London’s Central Line (2013) and Inequality and the 1% (2014).

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The most striking feature of Unequal Health, which should not surprise geographers, is the enduring effect of place. Just as Robert Sampson in Great American City: Chicago and the enduring neighbourhood effect (2013) has documented how where you are born and live has a lasting influence on your health, wealth, and happiness, so too does Dorling with regard to London. The opening section of Unequal Health characterises the United Kingdom’s (UK) capital city as home to persistent inequalities that have changed little since the time of Dickens in Victorian London. However, this is not an isolated case. For example, in documenting infant mortality between 1905 and 2005, Dorling shows that while substantial progress has been made, contemporary rates are not uniform across areas. In general the lowest rates are found in parts of the south with rates rising as you travel north. This is the geography of inequality that has two parts; first, it is the inequality within cities, and second, the inequality within the country, or richer areas over poorer areas.

An interesting aspect that Dorling highlights through the second section of the book is the record of New Labour, the UK government from 1997 to 2010. In spite of the sustained discourse of targeting health inequalities in the UK, inequalities actually got worse. The lack of improvement was a significant failure for the Labour government. As Dorling shows, this is because a number of the policies introduced during the period had an adverse effect. A major example in Unequal Health is income inequality. This is explored through changes in funding to health services, cuts to subsidised health programmes aimed at helping the very poorest, and changes to inheritance tax. These changes affect the population in direct and indirect ways. For example, changes to the provision of health services by reducing coverage of a community midwife programme would not have the same impact on people with better financial resources. They can pay for private treatment and remove themselves from the vagaries and variation of local provision. At the same time, they benefit from changes to tax systems that favour higher earners or asset rich groups.

These actions have helped to entrench health inequalities throughout society. A tangible result, according to Dorling, is the outcome of the 2010 UK general election. In failing to reduce health inequalities, the Labour government failed to narrow the discrepancy in life expectancy between rich and poor. Dorling argues that in failing to tackle this inequality the number of potential voters who traditionally vote Labour (poor) and who traditionally vote Conservative (rich) were not evenly matched in marginal constituencies. The result of this legacy of the Labour government was that there were fewer potential Labour voters to participate in the election, resulting in the Conservative and Liberal Democrat coalition government.

Unequal Health is packed full of interesting figures, charts, and maps. One example is the examination of the Gini-coefficient (Gini is a scale that ranks income inequality in which the higher the score, the greater the level of inequality). In particular, during the 1990-1997 Conservative government of John Major the Gini-coefficient decreased. However, whether this was due to changes in the tax system or policy initiatives compared with the effects of the economic recession in the late 1980s is not clear. However, it does raise interesting questions over economic recessions and their effects on health (Stuckler and Basu, 2013). As Dorling has shown in other recent work, not only has the current recession affected the poorest worst of all, the rich have remained relatively unscathed (Dorling, 2012), further entrenching inequalities within society.

Unequal Health explores the despair that growing inequality causes by a close examination of suicide in Britain during Conservative governments. Dorling concludes that there have been 35,000 suicides that would not have happened if a different government had been in power. The data shows that there were indeed spikes during both the Macmillan Conservative government (1957-1963) and the Thatcher administration (1979-1990). However, there is little difference between governments outside these two eras. In fact, the period of the Heath Conservative government (1970-1974) shows a dramatic reduction compared to the Labour administrations that pre- and succeeded it. Further research in this area would be greatly welcomed. The author admits that the study of suicide rates is a very crude analysis. However, it emphasises two themes that continue throughout the book: first, the deeply political nature of public health (see also Beaglehole et al., 2004); and, second, how statistics and information are (or can be) used, and what arguments are extrapolated and developed as a result.

The final sections of the book deal with data representation and communication, focusing on ways of recording, presenting and using social statistics in order to maximise reach, impact and application. The approach favoured by Dorling and implemented throughout Unequal Health is to use graphs and/or figures in conjunction with a personal story or clear emotive narrative. The effect is to communicate central messages far better than streams of data or complex modelling could achieve. It is a characteristic of Dorling’s large body of academic work. Moreover, there are practical uses for the deployment of data in this way, for example, the inclusion of similar evidence in health equity assessments and local health activism by Jason Corburn in Towards a Health City (2012) and Healthy City Planning (2013). In these Corburn advocates adaptive urban health justice, uniting planning and social justice to reduce persistent health inequalities by incorporating local knowledge and experience into planning decisions. The use of quantitative data and personal stories is beneficial for including disadvantaged groups in policy and planning resolutions.

Overall, Unequal Health is an excellent collection of articles. It is a useful and valuable resource for academics, researchers, and students. The work mainly concerns the UK, but that does not mean it is inaccessible to readers from around the world. Many of the conclusions and lessons drawn from the text are applicable to other developed and developing countries. A minor issue could be taken with Dorling’s prioritisation of his own experience over the marginalised voices that he describes, but this should not put readers off. Nor should the lack of any engagement with social theory. Unequal Health is a book that develops an understanding about contemporary society through primarily quantitative data. The book is unreservedly and unmistakably political. It is a strongly argued call for politicians, activists, and citizens to embrace ideas of the left, ideas that Danny Dorling suggests will reduce health inequalities and make society a more equitable place. That cannot be a bad thing.